Incorrect Patient Responsibility Dispute Letter

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If you have a received a bill from your provider for an amount different that what your health insurer provided on your Explanation of Benefits, this template gives you everything you need to dispute the bill with your provider. A guide is included to ensure you have the information you need to complete and submit the dispute letter.

If you have a received a bill from your provider for an amount different that what your health insurer provided on your Explanation of Benefits, this template gives you everything you need to dispute the bill with your provider. A guide is included to ensure you have the information you need to complete and submit the dispute letter.

Letter Sample:

Discrepancy Details: (Choose One)

- Incorrectly applied patient responsibility: The provider billed me $[Billed Amount], while my insurance EOB states I am only responsible for $[Correct Patient Responsibility].

- Insurance adjustment not applied: The insurance company shows an adjustment of $[Adjustment Amount] that has not been deducted from my provider bill.

- Deductible/Co-pay incorrectly charged: My insurance has confirmed that this charge should have been covered as part of [ex. preventive care, in-network benefits, etc.].

- Out-of-pocket maximum met: My insurance states that I have met my annual out-of-pocket maximum, yet I am still being billed for services.

I request that your office review this discrepancy and correct the billing statement accordingly.

If necessary, please contact [Insurance Company Name] at [Insurance Customer Service Phone Number] to verify the correct patient responsibility amount.  Billing a member a different amount than the insurer lists on the Explanation of Benefits is a violation of your contractual obligation with [Insurance Company Name].